A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect?
13% weight loss.
Bulging anterior fontanel.
Bradypnea.
Capillary refill 3 seconds.
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale
A 13% weight loss indicates severe dehydration. Dehydration is classified based on the percentage of body weight lost, with severe dehydration being more than 10%6.
Choice B rationale
A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. In dehydration, the fontanel is typically sunken due to fluid loss.
Choice C rationale
Bradypnea, or slow breathing, is not a common sign of dehydration. Dehydration often leads to tachypnea, or rapid breathing, as the body tries to compensate for fluid loss.
Choice D rationale
A capillary refill time of 3 seconds is within normal limits. In severe dehydration, capillary refill time is usually prolonged, indicating poor perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale
Budesonide via dry-powder inhaler is a corticosteroid used for long-term control of asthma. It is not effective for immediate relief of acute asthma exacerbations.
Choice B rationale
Cromolyn via metered-dose inhaler is a mast cell stabilizer used for long-term control of asthma. It is not effective for immediate relief of acute asthma exacerbations.
Choice C rationale
Albuterol via jet nebulizer is a short-acting beta-adrenergic agonist that provides rapid bronchodilation. It is the medication of choice for immediate relief of acute asthma exacerbations.
Choice D rationale
Montelukast orally is a leukotriene receptor antagonist used for long-term control of asthma. It is not effective for immediate relief of acute asthma exacerbations. .
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice D rationale
Tetralogy of Fallot is a congenital heart defect that includes four heart abnormalities: ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta. These defects cause altered blood flow and reduced oxygen levels in the blood.
Choice A rationale
Asthma is a chronic respiratory condition characterized by airway inflammation and bronchoconstriction. It is not commonly associated with tetralogy of Fallot.
Choice B rationale
Polycythemia, or an increased number of red blood cells, can occur as a compensatory mechanism in response to chronic hypoxia in tetralogy of Fallot. However, it is not a primary condition associated with tetralogy of Fallot.
Choice C rationale
Pulmonary hypertension is a condition characterized by increased blood pressure in the pulmonary arteries. While it can occur secondary to congenital heart defects, it is not a primary condition associated with tetralogy of Fallot.
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